International Consensus Statement on the Management of Hypotension With Vasopressors During Caesarean Section Under Spinal Anaesthesia

Abstract

(Anaesthesia. 2018;73:71–92) The objective of this comprehensive consensus statement was to provide practical and independent advice to physicians for treating and managing spinal anesthesia-induced maternal hypotension in both resource-rich and resource-poor environments. This clinical best practices summary was necessary as there has been much variation in the methods used to manage spinal anesthesia-induced hypotension during cesarean section, and maternal hypotension increases risks to both maternal and fetal/neonatal health. While generalized recommendations have been made for the management of this problem by professional organizations, the authors indicated this was the first consensus statement providing specific, pragmatic recommendations for managing spinal anesthesia-induced hypotension.

Thoracic ultrasound evaluation and B-type natriuretic peptide value in elective cesarean section under spinal anesthesia

“…Many studies have tried to address the management of hypotension during spinal anesthesia for cesarean section [21][22][23]. Given the morbidities associated with maternal hypotension, affecting both mother and child, a recent international expert consensus recommended the use of vasopressors to maintain systolic arterial pressure to ≥ 90% of baseline [24]. How this may reduce the administration of fluids and, therefore, at least potentially, reduce fluid overload is still a matter of debate.…”

Prophylactic phenylephrine and fluid co‐administration to reduce spinal hypotension during elective caesarean section in a resource‐limited setting: a prospective alternating intervention study

“…The administration of a higher volume of fluid might have produced different results. We also found a higher incidence of hypotension than expected, possibly since we studied only women having elective caesarean section [3,20]. We postulate that women undergoing emergency caesarean section are often in labour, may have a higher baseline concentration of circulating endogenous catecholamines and raised cardiac output, and thus be less likely to develop spinal hypotension.…”

“…. Spinal anaesthesia for caesarean section has maternal and neonatal benefits; however, 78% of deaths related to anaesthesia in South Africa occur during spinal anaesthesia, and more than half of these are associated with untreated spinal hypotension fluid loading and left lateral uterine displacement to minimise the incidence of hypotension after spinal anaesthesia[3]. Titrated phenylephrine infusions require both appropriate syringe drivers, as well as skilled anaesthetists trained to adjust the rate of infusion in response to maternal haemodynamic changes.…”

Future blood pressure monitoring for cesarean delivery

“…I assume that the study showed the clinical benefit of using continuous monitoring, not the device. Continuous monitoring is theoretically ideal; however, the routine application to all cesarean patients is not feasible, including the costs, and cannot be justified by the current evidence [2]. Systolic blood pressure (SBP) is commonly considered as a parameter reflecting organ perfusion, but it is less meaningful than mean arterial pressure (MAP) [3].…”

“…Systolic blood pressure (SBP) is commonly considered as a parameter reflecting organ perfusion, but it is less meaningful than mean arterial pressure (MAP) [3]. Although MAP sounds physiologically reasonable and the recent experts' opinions support the importance [2], there are no well-designed studies. We conducted a retrospective study and found minimum MAP < 70 mmHg and longer duration of SBP < 100 mmHg were related to lower umbilical arterial pH [4].…”